 Thank you very much. It's a real pleasure to be here again. I was at the first ancestral health symposium 11 years ago, and I always wanted to come back. Sadly, I can't yet do it in person due to an unusual busy schedule for this time of year. But fortunately, technology came to the rescue, allowing us to discuss the lifestyle of a traditional population that paradoxically didn't have access to any modern technology. And I would like to dedicate this lecture to my late mentor and friend, Stefan Lindenberg, who was the researcher from Sweden who lived, worked, and collected samples in this island off the coast of Papua New Guinea called Kittava. And this was an island that, when Stefan was there in 1990, was an island characterized by the absence of electricity. It's in a small island. The absence of telephones or motor vehicles, except for one motorboat that was barely used. For some reason, they preferred the old ways. And when Stefan was there in late 1990, as I mentioned, there were about 2,200 people living in villages or hamlets, where each village had 2,400 people. And regarding the population itself, in late 1990, there were 1,816 subjects that were estimated to be older than three years old. And Stefan and his family decided to go to this island and live there for seven weeks, from November to December of 1990. And this led to the Kittava study that many people in the ancestral health community know about. And this was the doctoral thesis of Stefan Lindenberg, who was a Swedish physician who sadly passed away in 2016. And he was also at the first ancestral health symposium in LA, at the UCLA in 2011, so 11 years ago. And I was fortunate to be there with him and to be able to be his friend and to be his mentee. He really taught me a lot. And regarding the Kittava study, Stefan noticed that there was minimal Western influence in this population, except for clothing, tools, smoking, kerosene lamps, some costumes such as soccer and education, morals and religious beliefs. And there was some, but not that much sanitation. And regarding their diet, as expected, this was a traditional one, as you can see in these pictures where you see fish, where you see uncooked and then prepared ready to eat tubers. So this was a diet composed mainly of tubers, fruits, fish and coconuts, supplemented with a few local foods and with virtually no imported foods. And here you see the distribution of these foods in terms of the weight, in terms of the energy, and in terms of the various macronutrients. I should mention that there were some foods that were eaten less than once a week, such as chicken, eggs, seals, octopus, shellfish, turtles, flying foxes, pork, guadillo, which is a fruit, breadfruit, sugarcane, pendenas nuts, pomelo, mushrooms, and various other items. So this was an omnivorous diet, but as you can see here, this was not a high animal, didn't have a high percentage of animal foods. Nevertheless, it was not a vegetarian and of course not a vegan diet. So we are talking about a traditional non-hypercaloric diet with a macronutrient distribution that doesn't really fit most narratives about what a healthy diet should be, as you can see here. So you see that total fat intake was low, which contrasts to what low-carb authorities recommend and to what is the fat content of the increasingly popular and in my view, much hyped Mediterranean diet. But it apparently fits some plant-based low-fat narratives that have been using this study to support their narrative. Nevertheless, most of the fat ingested by Kitavans was saturated, which is well above the 10% limit set by the health institutions of several countries. Another striking difference to current schools of thought, particularly the ones focusing on aging and or sarcopenia, is the low content of protein of the Kitavan diet. So you see that on a 2,200-kilocalorie diet, this leads to a mere 55 grams of protein and on a 3,000-kilocalorie diet, it leads to only 75 grams of protein. Obviously, given what we just discussed, carb-wide retin intake was high, representing almost 70% of the total energy intake on a typical Kitavan diet. So this means that this is not a diet that fits any current narrative on what a healthy diet should be. Regarding fluid intake, I should mention that they drank immature coconut water and also rainwater. And since we are talking about fluid intake, this inevitably leads to the question, what about salt, which is also a big thing nowadays in the ancestral and in the nutrition community as a whole. And Staffan Lindenburg reported in his doctoral thesis, which was entirely about the Kitavan study that roughly 200 grams of sea water was added to a pot, where about 5 kilograms of food, mainly tubers, was boiled in rainwater. So with a sea salt level of 3.5%, this would lead to an estimated daily sodium intake per 24 hours in the order of 2.3 to 3 grams per day. And together with this traditional non-hypercaloric moderate sodium diet, Kitavan's had a moderate to active physical activity level, which was 1.7 multiples of the basal metabolic rate. So in accordance with this, and despite their high carbohydrate diet, which to some schools of thought is inherently obesogenic, we see that 93% of women and 87% of men of a sample of 138 Kitavan natives, age 40 to 6 years, had a BMI below 22. And not a single individual in this sample was overweight or obese, whereas in a Swedish, sex and age matched control population, the prevalence of overweight was 38%, and the prevalence of obesity was 10%, and the prevalence of morbid obesity was 2%. So in accordance with these observations, Staffan found a lower waist to height ratio in a sample of 163 Kitavans, age 20 to 86 years old, compared to 224 healthy sweets, age 25 to 74 years. And it should be mentioned that Staffan didn't detect any evidence of famine and malnutrition. So this cannot explain the absence of obesity and overweight, which is a typical argument used by some people. In fact, Staffan said that lack of food is an unknown concept and that the surplus of fruits and vegetable regularly rots or is eaten by dogs. So these people do not seem to know what famine is. And Staffan was able to collect blood samples from various Kitavans. So let's now look at specific biomarkers. And we start with blood lipids, where we see that total and LDL cholesterol aren't exactly optimal, according to the guidelines on cardiovascular disease prevention adopted by most countries. And a possible explanation for these results is the Kitavans higher than recommended saturated fat intake, with the highest contribution coming from loric acid, whose main source in the Kitavan diet was coconut. And something that attracted my attention was the fact that despite their fairly high intake of loric acid, their serum cholesterol asters have very little loric acid. In fact, the fatty acid with the highest concentration in serum cholesterol asters is palmitic acid, despite the Kitavan diet being low in these fatty acids. So how can we explain this finding? What does this mean? I believe this is merely a physiological normal consequence of their high carbohydrate intake. And let's just briefly review the ultra simplified version of the biochemistry behind what I'm saying. So here you're seeing the liver on your top left. And now you will see an hepatocyte. And under a high carbohydrate diet, the absorbed glucose that enters the cell will be obviously subject to glycolysis, which will generate pyruvate. And pyruvate will be then converted to acetyl coenzyme, which enters the citric acid or the crab cycle in the mitochondria, where it will generate citrate. And this will continue to generate ATP, and especially the reduced electron carriers, NADH and FADH2. But when the flux in the cycle is high, or put in other words, when ATP levels are high, citrate will accumulate, which is then able to cross the mitochondrial membrane and enter the cytosol of the hepatocyte. And once in the cytosol, citrate will be converted to acetyl coenzyme A, which will then form maloneal coenzyme A, which in the presence of the enzyme fatty acid synthase will lead to palmitic acid. And palmitic acid or palmitate is the main product of this biochemical phenomenon called the novel hypogenesis. And indeed, that is what we see in the fatty acid profile of serum cholesterol esters of ketavons. You see a high content of palmitic acid. And we know that this is so, despite their low intake of palmitic acid, as I mentioned. So this comes mainly from this process, the novel lipogenesis that occurs because of the high carbohydrate intake. And we know that palmitate or palmitic acid can be further elongated or more important to our discussion, de-saturated to form other fatty acids such as palmitolic acid or palmitolate. And in accordance with what I just discussed and showed you here, we know that palmitolic acid is high in the serum cholesterol esters of ketavons. So in summary, I think the explanation for this high palmitic acid and the high palmitolic acid results that we find in ketavons and that you are seeing here in this table is the increase the novel epogenesis caused by their high carbohydrate intake. And I think this is further confirmed by their blood lipid profile. More specifically, there are somewhat elevated triglyceride and low HDL cholesterol levels when taken as optimal levels, what some propose, which is a triglyceride level below 100 milligrams per deciliter and an HDL cholesterol level of at least 60 milligrams per deciliter. And despite this apparently suboptimal blood lipid profile and their high carbohydrate diet, we know as we just showed that ketavons were not overweight and even more interesting, their fasting plasma glucose levels varied between 56 and 81 milligrams per deciliter. Whereas in a sample of apparently healthy sweets, it ranged from 83 to 106 milligrams per deciliter. Moreover, the same ketavons had a lower fasting plasma insulin concentration varying between two and six international units per milliliter compared to healthy sweets where it ranged from four to 11 international units per milliliter. Interestingly, and as you can see here in this graph, fasting insulin increased with age in Sweden, but it didn't increase with age in ketavons. Furthermore, and partially because of their excellent insulin sensitivity and body composition, ketavons also had significantly lower fasting plasma leptin levels compared to healthy sweets. And an interesting and related finding that I can't yet show you because it is preliminary and because we haven't published the data yet is the low adiponectin level that we just found in ketavons when compared to sweets. And as you know, multiple studies suggest that adiponectin is an anti-inflammatory and an insulin sensitivity sensitivizer molecule. So this means that having higher levels of adiponectin is normally associated with better disease outcomes. Nevertheless, this is not what we find in ketavons. Their levels are very low and are significantly lower than sweets. And there are large epidemiological studies fully adjusted for non-confounders that indicate that adiponectin is paradoxically associated with increased all-cause and cardiovascular mortality rates, which makes these findings even more interesting. And we hope to finish the manuscript by the end of the summer so that it can be published before the end of the year. And another interesting finding is an apparent absence of acne in more than 1,000 ketavons, including 300 aged 15 to 25 years old. As you know, acne is more prevalent in adolescents and young adults. And I think this is to be expected since one of the causes of acne appears to be insulin-resistant, combined with hyperinsulinemia. And coming back to the fatty acid profile of ketavons, we see that their serum cholesterol esters were high in the omega-3 fatty acids, EPA and DHA. And this despite the fact that their intake of omega-3 fatty acid was not very high, it was a moderate intake. And a likely explanation for these lies in their very low intake of omega-6 fatty acids, particularly linoleic acid, which can negatively affect the status of EPA and DHA. And in accordance with what we just discussed, the results from resting ECGs in ketavons indicated that there was in this population an apparent absence of ischemic heart disease, which is in accordance with previous observations done by other physicians working in the Trawberry and Islands. Ketava is one of the islands belonging to this archipelago, the Trawberry and Islands. And this is further strengthened by semi-structure interviews conducted by Stefan in more than 200 adult ketavons, which revealed that chronic exertion related chest pain, paralysis of arms and legs, and sudden inability to speak were unknown to these people. And only three cases of spontaneous sudden deaths in adults were known to these people in the last 100 years. And the dominant causes of deaths in Ketava were infectious, primarily malaria in children, accidents, pregnancy complications, and also old age. Yes, old age, because contrary to popular belief that traditional populations do not live past the age of 40, there were 125 subjects in Ketava that were estimated to have 60 to 96 years. And these represented 6% of the entire population. And this is in line with the average model age of adult deaths for hunter-gatherers, horticulturalists, and other traditional populations, which ranges from 68 to 78 years, according to this 2007 review by the anthropologists Michael Gerven and Healert Kaplan. This is very striking what I'm about to show you. And I think many people in the audience already know this. Nevertheless, I think it's important to remember it that in Ketava, 76% of men and 80% of women smoke. Despite this, and as we've seen, there was an absence of obesity, a low prevalence of hypertension, an apparent absence of the metabolic syndrome, type 2 diabetes, stroke, and ischemic heart disease. And this is in accordance with the Ketavan's higher levels of the heteroprotective antibodies, namely anti-phosphoryl colline. And they also presented as expected for a traditional population, a high prevalence of infectious antibodies, namely antitreponemyl and anti-cytomegalovirus antibodies. Given this, we decided to measure using what Stefan did in the 1990s, low-grade chronic inflammation in Ketavan's, because we know that low-grade chronic inflammation may cause or contribute to insulin resistance, to type 2 diabetes, to endothelial dysfunction, to hypertension, atherosclerosis, thrombosis, ischemic heart disease, and ischemic stroke. All of this absent or rare among the Ketavan's as we just showed. And the biomarker that we decided to analyze was C-reactive protein, which has been associated in multiple epidemiological studies with a higher risk of type 2 diabetes and a higher risk of cardiovascular mortality. And indeed, we know that CRP adds prognostic information on cardiovascular risk comparable to blood pressure or cholesterol. We are circulating levels below 1 milligram per liter. 1 to 3 and above 3 indicate a relative cardiovascular risk, which are lower, moderate, and higher respectively. Whereas values above 10 milligrams per liter typically reflect an acute inflammatory response such as those that we observe in infections or trauma. And so we decided to analyze this biomarker, serum high sensitivity CRP in 40 years old and older Ketavan's and compared it to Swedish controls matched for age and gender. As you can see in this table, there were small but significant difference between Ketavan's and Swedish controls for all CRP levels and also for CRP levels below 10 with lower CRP for Ketavan's. And when we compare these results with reported CRP levels for other traditional populations, we find that these low levels that we find in the Ketavan's agree with the low CRP among the Schwarz forager or culturalists of the Ecuadorian Amazon and also the subsistence agriculturalists from rural Ghana. But contrasts with the higher CRP levels among the hearts, the hunter-gatherers of Tanzania and even more with the Tzimani forager or the culturalists of Bolivia who had a median CRP just below three milligrams per liter, presumably because of chronic infections. So what can we conclude from these studies? I think we can fairly say that Ketavan's have an apparent absence of overweight and obesity and also of cardiometabolic disorders. We can also say that Ketavan's have a higher physical activity level much higher than what we find in most people in industrialized countries. We can also say that the Ketavan diet is a low-fat, nevertheless a high-saturated fat diet and it is low in omega-6 fatty acids, particularly linoleic acid, and it is moderating omega-3 fatty acids, particularly EPA and DHA. We can also say that their diet was high in carbohydrates but it was low in added sugars and cereal grains and apparently it was high in the so-called acellular carbohydrates. We can also say that it was a low-protein diet and that it was moderating salt and we can also say that this diet leads to an adequate energy balance. So this is what we know for sure. Now let's look at what we don't know but speculate to be so. So these are of course speculations. Nevertheless I think that this is very possible. So Ketavan's have a high sun exposure so this means that their vitamin D levels are expected to be in the optimal range. Unfortunately Stefan when he was there he didn't analyze vitamin D and he wasn't very interested in this molecule. We can also speculate based on what we know from other traditional populations that Ketavan's have circadian rhythms in sync with a natural light-dark cycle and that they do some form of time-restricted eating, particularly during the night. Stefan told me that they eat breakfast. Normally they don't eat lunch but they eat some fruit during the day and then they eat a larger dinner. And we can also speculate that Ketavan's have inadequate micronutrient intake and status and we can also speculate based on what we know from other traditional populations that Ketavan's have a rich and diverse gut microbiome and this is because not only of their diet but particularly because they live in a non-sanitized environment. We can also speculate that Ketavan's have a low xenobiotic exposure or let me rephrase this. We can speculate that they had a low xenobiotic exposure. Unfortunately 30 years have passed and now we don't know how their environment is anymore. So this is what we can say from the Ketavan's that Stefan met 32 years ago. Now we don't know if this is the case anymore. So what I think that this study should bring us in my view is the notion that we should look at the forest and not only at the trees. So when we just focus on diet or when we just focus on certain nutrients, certain macronutrients to be more specifically such as carbohydrates or fat which are the main ones currently in debate in various nutritional debates or if we just focus on exercise or sleep or stress or the microbiome or whatever I think we are missing the forest for the trees. If we really want to know what can we emulate from the Ketavan diet and lifestyle the only thing that I can say is that we can emulate everything because if we just try to emulate a few things we might not have the result that we are expecting because one thing is to have particular aspects of the Ketavan diet and lifestyle in this whole diet lifestyle and environment and the other thing is to bring it to our own ecological niche the modern one where perhaps some of these features will not produce desirable outcomes. So we should always look at the big picture and not be lost in the details and now I'm open to any questions that you may have it was a pleasure. Thank you very much for your attention. That was an awesome talk I have two questions the first one is from the upcoming dental panel we're curious if there are any studies on the amount of caries periodontal disease and you know jaw morphology malocclusion. Unfortunately no so Stefan unfortunately didn't look into that but if we look at what we know from other traditional populations we can speculate that perhaps what you just mentioned is rare in the Ketavans but I'm merely speculating here. Okay thank you the second question is for myself and I'm a dentist so I always warn my patients if they smoke cigarettes there might be in for some dental trouble but to that extent we we associate sun exposure with cancer and clearly you know they didn't have any problem with skin cancer so do you think the that overall picture of health means that you can squeeze in some things that we might think are detrimental to modern humans but it won't be for them? So as you know there are three major types of skin cancers the highly aggressive and often fatal melanoma and the less severe basal cell and squamous cell carcinomas which are grouped together as non-melanoma skin cancers and in his doctoral thesis Stefan states that protracted illness during several months or years was practically unknown as were successfully growing visible tumors this suggests that skin cancer was rare and in my opinion I think this is in line with what the scientific literature regarding sun exposure and skin cancer indicates so indeed we know that cumulative sun exposure can cause non-melanoma skin cancers particularly in people with less pigmented skin in people with a more darkly pigmented skin and hence more evolutionary adapted to chronic year rounds and exposure which would include the ketavans of course the incidence of non-melanoma skin cancer is low regarding melanoma the literature is less clear but there is epidemiological data suggesting that paradoxically indoor compared to outdoor workers have a higher incidence of this type of cancer moreover a melanoma incidence has consistently been associated with intense intermittent sun exposure furthermore certain photo-products such as for example vitamin D and some of its metabolites lumesterol and superstrawls have been shown to possess anti-melanoma activity and finally sun exposure induces the synthesis of melanin which is a pigment that protects the skin from UVB, UVA and blue visible light against damage so what can we conclude from all of this I think that we can conclude that most people in the industrialized countries have a very dysfunctional relationship with the sun most of the time they avoid it and for brief periods say during summer or tropical winter vacations they have excessive sun exposure sometimes even sunburns which in turn causes DNA damage and increases the risk for melanoma and also non-melanoma skin cancer and this to me resembles someone who is heavily sedentary and one day decides to walk into a gym and squat 200 pounds thus suffering an injury and blaming it on the exercise when the only single one should blame in this case is his or her stupidity so sensibly exposing yourself to the sun is something that I think most people should do and this is exposing to the sun on a daily basis but during a short period of time and always avoiding sunburn thank you thank you for your study or not to revisit the study I mean it was great you mentioned some of the serum percentages of fatty acids but left out linoleic acid and I was wondering what the average for those was thank you so I only mentioned total omega-6 intake which was below 1% of total energy so this means that linoleic acid intake was below 1% of total energy intake which is lower than the 10% recommended by summer health authorities and the 2% that appears to be the cutoff for the adequate conversion of the omega-3 fatty acid alpha linoleic acid into DHA on a low EPA in DHA diet such as a vegan diet thank you for your talk one thing that occurred to me and I'm not familiar with the study at all but did anybody look at the difference in the social structures of the two groups I'm just imagining that the katavans have a very close social structure which could have potentially immense health conferring benefits compared to the Swedes anybody take a look at that variable Thank you I agree with you but unfortunately all I know is what Stefan told me in private so he didn't do any structured analysis of this characteristic this very important characteristic and an important determinant of longevity and well-being nevertheless I think that what you just mentioned is what we find in most traditional societies and particularly I think this is also the case in the ketavans but I'm only speculating and only telling you what Stefan told me about what he saw when he was there because he lived with the ketavan family so he experienced that but I don't know if this is the case for all of the villages if this is the case for most of the families in ketava all right thank you very much thank you thank you for your talk you mentioned a couple of protective in antibodies like anti-cmv antibody and living in a dirty environment any speculation what would happen to a ketavan if he was transferred to a sterile environment like Sweden or the US in regards to autoimmune disease obrigado obrigado thank you that's a very good question so we know that infections are a trigger of autoimmunity however parasites such as helmets are paradoxically protective against the development of various autoimmune diseases furthermore a disbiotic microbiota which can be caused by the typical western diet and lifestyle is a contributor to autoimmunity so collectively I think that this suggests that if a ketavan that has been exposed to infectious agents is now transferred into a sterilized environment such as the one that we have in our countries which is also characterized by inadequate sun exposure low physical activity circadian disruption and the typical western diet he or she would have a higher risk for autoimmune diseases as you suggested